South African Family Practice 2017; 59(1):41–45 http://dx.doi.org/10.1080/20786190.2016.1254930 S Afr Fam Pract ISSN 2078-6190 EISSN 2078-6204 Open Access article distributed under the terms of the © 2017 The Author(s) Creative Commons License [CC BY-NC 3.0] http://creativecommons.org/licenses/by-nc/3.0 RESEARCH

Perceptions of students regarding the effects of the implementation of the act of 1999 on a South African University campus

M.W. Khana, V. Hiraa and F. Haffejeea* aDepartment of Basic Medical Sciences, Durban University of Technology, Durban, *Corresponding author, emails: [email protected], [email protected]

Background: among adolescents is high. In order to curb the habit, restrictions on use of tobacco products in public places were implemented in South Africa. This study aimed to explore students’ perceptions of whether the implementation of smoking restrictions and no-smoking signs have had any effects on smoking behaviours on campus. Methods: A quantitative cross-sectional study was conducted amongst university students, who completed a self-administered questionnaire. Results: Students were aware that smoking causes disease and that second-hand smoke is dangerous. The majority were pleased that there was a smoking regulation in effect, but disagreed that it created a healthier atmosphere. Many would like a total ban enforced in restaurants, clubs, bars and university campuses. They felt that there were insufficient non-smoking signs in public areas. Many smokers stated that they ignored regulations and only a minority stated that the policy encouraged smokers to quit. Conclusion: Smoking among students has decreased over the years. This has been accompanied by an increase in knowledge of the harmful effects of smoking. Regulations have thus had a positive effect; however, additional efforts are required to motivate more people to quit smoking altogether and to prevent young people from taking up the habit.

Keywords: smoking, smoking regulations, South Africa, tobacco control act, university students

Introduction Methods is the leading cause of preventable illness and A quantitative cross-sectional study was conducted from death in developed countries and the third leading cause of February to May 2015 amongst students attending a tertiary death in South Africa, where 38% of adolescents have tried institution in Durban, KwaZulu-Natal, South Africa. Questions smoking.1 It has led to an increased prevalence of cardiovascular were compiled from established literature within the field.9,10 The diseases, cancer and respiratory problems.2,3 questionnaire included items on tobacco use and exposure as well as knowledge of and attitudes towards smoking. Current Due to these adverse effects on health, restrictions on the use of and ex-smokers were also required to answer a section on tobacco products in public places were implemented in South smoking behaviour and cessation. Demographic information Africa by the enactment of the Tobacco Products Control was requested from all participants. The questionnaire comprised Amendment Act of 1999 (TPCAA), which limited smoking to 60 questions and took approximately 15 min to complete. certain areas of restaurants, clubs, shopping centres and other Attitudes on several statements were assessed using responses public places.4 This law, which prohibited smoking in the general along a five-point Likert scale (strongly agree to strongly area of these public places, was predominantly for the well-being disagree). of second-hand smokers and did not encourage people to stop smoking altogether.5 It was thus not accompanied by an The surveys were reviewed thoroughly by the study team and educational campaign to raise awareness of the detrimental subsequently piloted for reliability to ensure that language was effects of smoking on health.6 appropriate for the local context prior to administration. Using a total student population of 22 303, a confidence level of 95% and In 2005, the amended TPCAA raised the legal age of buying a confidence interval of 5%, a minimum required sample size of tobacco products from 16 to 18 years. It also made it illegal to 384 was calculated. As we expected an approximate return of smoke in a car with a child under the age of 12 years.7 85%, a total of 450 questionnaires, in the English language, were Furthermore, it implemented anti-smoking media campaigns, distributed. Students, 18 years and older, registered for full-time and health warnings on tobacco products.8 Notwithstanding studies at all levels, were recruited by convenience sampling at this, smoking has not been completely banned at tertiary several locations (e.g. outside the library, cafeteria and lecture institutions in South Africa but no-smoking signs are present at halls) on three Durban-based campuses of the Durban University entrances to all buildings and even along stairwells. The of Technology. Students who were in the above-mentioned perceptions of South African students concerning the areas were approached by members of the study team and implementation of smoking restrictions and no-smoking signs invited to participate in the study. Those interested were on university campuses are as yet unknown. This study aimed to provided with a written information letter and any queries were explore students’ perceptions of whether the implementation of addressed. Signed consent was provided by all participants prior smoking restrictions and no-smoking signs have had any effects to answering the self-administered questionnaire. Confidentiality on smoking behaviours on campus. was maintained and no identifying information was collected on

South African Family Practice is co-published by Medpharm Publications, NISC (Pty) Ltd and Informa UK Limited [trading as the Taylor & Francis Group]. 42 S Afr Fam Pract 2017; 59(1):41–45

Table 1: Demographics of study population of the respondents (50.4%) reported not living with any smokers in their household. More than half of the respondents (61%) Item Total Smokers Ex-smokers Non- stated that they have tried a cigarette at some time in their life. smokers The age group of 17 to 19 years was the most common for first 100% 19.6% 10.1% 70.2% trying a cigarette (36%), followed by the 14- to 16-year age group (n = 386) (n = 76) (n = 39) (n = 271) (28%). There was no difference between smoking status among Age group (years) the different ethnic groups (p = 0.121). The average duration that 18 22.4 (86) 15.1 (13) 5.8 (5) 79.1 (68) respondents had smoked was 4.6 ± 3.2 years. 19–24 69.8 (266) 19.5 (52) 11.6 (31) 68.7 (183) The most common reason for starting to smoke was because ‘it > 25 7.8 (30) 34.5 (10) 6.9 (2) 58.6 (18) seemed fun’ (31.3%). The main reason for currently smoking was Gender stress (42.0%), followed by the perception of smoking being Male 54.4 (211) 30 (63) 11.4 (24) 58.5 (123) ‘cool’ (23.0%) and peer pressure (22.0%). People with smokers in Female 45.6 (176) 7.4 (13) 8.6 (15) 84 (148) their household were more likely to be current or ex-smokers than people with no smokers in their household (p < 0.001). Ethnicity Smokers were also significantly more likely to have been exposed African 66.6 (255) 16.5 (42) 11.8 (30) 71.7 (183) to second-hand smoke at home in the past seven days (p = 0.003). Coloured 3.6 (14) 21.4 (3) 14.3 (2) 64.3 (9) Indian 22.8 (87) 28.7 (25) 3.4 (3) 67.8 (59) Significantly more males (30.0%) smoked than did females (7.4%; p < 0.001); however, there was no difference in the number of White 7.0 (26) 19.2 (5) 11.5 (3) 69.2 (18) cigarettes smoked between the genders (p = 0.62). Over a third Note: All sub-categories do not total 386 as some participants chose not of the smokers (38.3%) smoked 2 to 5 cigarettes a day and almost to answer some questions. another third smoked 6 to 10 a day (31.3%) while 16.5% smoked only one a day. A further 10.4% smoked between 10 and 20 Table 2: Knowledge of the effects of smoking on health cigarettes a day and 3.5% smoked more than 20 cigarettes a day. The majority of smokers did not smoke indoors (72.8%). Almost Knowledge of the hazardous effects of smoking % (n) two-thirds of the respondents (62.3%) reported exposure to second-hand smoke at university, more than half (57.5%) were I have been informed about the dangers of smoking 90.8 (357) exposed in public places and only 26.0% at home. Current and Smoking causes cancer 89.6 (352) ex-smokers were also significantly more likely to have tried or Smoking causes lung disease 88.5 (348) experimented with other smoked tobacco products as opposed Smoking causes heart disease 76.6 (301) to their non-smoking counterparts (p < 0.001). Smoking can aggravate tuberculosis 74.6 (293) Table 2 shows that there was a high level of knowledge of the Smoke from other people’s cigarettes is harmful to me 73.5 (289) harmful effects of smoking. The majority (90.8%) of respondents were aware of the dangers of smoking. They were aware that smoking causes cancer (89.6%), lung disease (88.5%), heart the survey document. Completed questionnaires were collected disease (76.6%) and that it can aggravate tuberculosis (74.6%). in a sealed ballot box separate from the signed consent forms. They were also aware that second-hand smoke was dangerous The study was approved by the Institutional Research Ethics (73.5%). Committee of the Durban University of Technology (IREC 009/15). Table 3 illustrates the perceptions regarding the smoking policy. All quantitative data were analysed using the SPSS® statistical The majority of participants were pleased that there was a package (version 23.0) (IBM Corp, Armonk, NY, USA). Likert-scale smoking regulation in effect (70.2%) but less than a third (30.1%) analysis was performed to analyse responses. The ‘strongly agree’ agreed that the regulation created a healthier atmosphere. and ‘agree’ categories were collapsed and the frequency of Almost a third stated that a ban on all smoking should be agreement subsequently calculated. Similarly, the ‘strongly extended to all restaurants, whereby smoking should not be disagree’ and ‘disagree’ categories were collapsed for the allowed in any restaurant even within designated smoking areas calculation of frequency of disagreement. Thus the final analysis (65.6%), and almost half would like total smoking bans in all was performed on a three-point Likert scale with the categories clubs, bars and pubs as well (44.3%). Over half (58.1%) stated that of ‘agree’, ‘unsure’ and ‘disagree’. Where applicable, a chi-square a ban should be implemented on all university campuses, while test or Fisher’s exact rest was used to determine the significance only 14.6% thought that the current regulation at university is of relationships between variables. A p-value of < 0.05 was well enforced. Many thought that there are insufficient no- considered statistically significant. smoking signs in public areas (42.2%).

Results There was only a marginal difference in the perception of the The demographic details of respondents are given in Table 1. A regulation between smokers, ex-smokers and non-smokers, with total of 393 respondents completed the questionnaire. There more ex-smokers and non-smokers being pleased with the were more males (54.4%) but this gender difference was not smoking regulation than current smokers (p = 0.046). Significantly significant (p = 0.09). Most respondents were Black African more non-smokers and ex-smokers also thought that there (66.6%), followed by Indian (22.8%), White (7.0%) and those of should be a complete in restaurants, clubs/bars mixed race (3.6%). and across all university campuses (p < 0.001).

The majority of the respondents (70.2%) were non-smokers, Only 19.6% indicated that the policy encouraged smokers to 19.6% were current smokers while 10.1% were ex-smokers. Half quit. The regulation has also had little impact on the number of Perceptions of students regarding the effects of the implementation of the tobacco control act of 1999 on a South African University campus 43

Table 3: Attitudes towards the smoking policy knowledge concerning the harms of smoking, supported the smoking regulations and would like a total restriction of smoking Factor n (%) in all indoor public places. Our finding of a prevalence of 19.6% Perception of the regulation of student smokers is lower than a previous report from 2006 I am pleased that the smoking regulation has been introduced 70.2 (271) where the prevalence of smoking among South African students was 26%.11 This would be due to the awareness of the health risks The regulation on public smoking has helped create a healthier 30.1 (116) atmosphere posed by smoking and possibly also due to the high cost of cigarettes as many ex-smokers reported that they stopped There should be a smoking ban in all restaurants 65.6 (256) smoking either because of health reasons or because of the high There should be a smoking ban in all clubs/bars/pubs 44.3 (171) cost of smoking. There should be a smoking ban on all university campuses 58.1 (222) Effect of the ban on perceived smoking behaviour Study participants showed a considerable knowledge of the adverse effects of smoking and the amount of knowledge has The regulation on smoking has encouraged smokers to quit 19.6 (76) 11,12 smoking increased since a previous study conducted in 2000 and 2006. A substantially higher proportion of young people are now Since the smoking regulation was implemented, less people are 30.8 (120) seen smoking in restaurants aware of the risk of heart disease (77%) compared with previously (30%).12 Whilst, in 2000, 70% of people were aware that smoking Since the smoking regulation was implemented, less people are 20.8 (81) 12 seen smoking in public places causes cancer, this number has now increased to 89%. The amendment to the TPCAA (in 1999) promoted the knowledge of Since the smoking regulation was implemented friends/family 27.1 (105) the dangers of smoking with the requirement of warning labels members have decreased the number of cigarettes they smoke on cigarette packages. The higher numbers of young people Since the smoking regulation was implemented many friends/ 14.9 (58) currently aware of the dangers of smoking attests to these family members have stopped smoking warning labels having some impact on them. Much like first Perception of smokers on cessation and the ban world countries, the younger generation could, knowing the I would like to stop smoking right now 53.5 (54) hazardous effects of smoking, be less likely to start smoking, I have tried to quit smoking in the past 71.2 (74) which also explains the decrease in its prevalence. The smoking regulations made me stop smoking altogether 13.7 (14) It is nevertheless disturbing that approximately a quarter of the The smoking regulations made me decrease the number of 32.0 (33) respondents reported not knowing that smoking causes heart cigarettes smoked disease and that it aggravates tuberculosis. Health-education The smoking regulations have had no effect on my smoking 39.6 (40) programmes need to be enhanced so that this knowledge habit reaches all people. It can perhaps be added to school curricula so that it directly targets young people at an age when they are vulnerable to commence smoking. Education programmes must people seen smoking in restaurants (30.8%) and public places also include information on the harmful effects of secondary (20.8%). Almost two-thirds (63.5%) of smokers stated that they smoke as many are unaware of this. smoke anywhere on campus therefore ignoring the regulation, as opposed to 21.7% who smoke outside, but within campus The perception towards the regulations on university campus was grounds. The remainder smoke away from campus. Over a positive in that most students were happy that these were quarter (27.1%) reported that the regulation has decreased the implemented and wanted them applied in other environments as number of cigarettes smoked by family members or friends, and well. Signage at university differs around various buildings. While only 14.9% reported a complete cessation of smoking by family these signs are present at the entrance to main buildings and and friends. lecture venues, there are none near the cafeteria and eating areas, which are places where students gather during their free time. The Most ex-smokers stopped smoking 2.0 ± 3.0 years ago. The main areas around the offices of the university staff also have little or no reason for quitting smoking was personal health (62.9%) signage. We propose a more uniform distribution of no-smoking followed by the high cost of smoking (19.2%). Only 13.7% signs as well as the allocation of specific smoking areas for attributed their cessation to the smoking policy. However, almost smokers. The smoking areas should be a considerable distance a third (32.0%) of the current smokers reported a decrease in away from lecture venues, cafeterias and offices. They should number of cigarettes due to the regulation while 39.6% said the preferably be in an open space that is not in parking areas or regulation had no effect on their smoking behaviour. walkways and that is a large distance away from buildings and gardens in order to create a healthier atmosphere. It is also Over half of the current smokers (53.5%) wished to stop smoking anticipated that the inconvenience of walking to these areas will henceforth, and many (71.2%) said that they have tried to quit in help decrease the number of cigarettes smoked and/or eventually the past but failed. A few (17.5%) had tried replacement result in cessation. Previous reports have shown that the therapies in an attempt to stop smoking and 23.3% had tried inconvenience placed by smoking restrictions reduced smoking e-cigarettes as a substitute. in adults.13 In addition, this will ensure that those who do not smoke are protected from the harmful effects of secondary smoke. Discussion Smoking amongst university students has been a concern due to Despite the presence of no-smoking signs on university its effects on health. Developing countries have a large campuses, most students were exposed to second-hand smoke prevalence of smokers with resultant bans and anti-smoking at university. As the signs are often ignored, stricter control 8 campaigns in an attempt to curb the habit. This study needs to be maintained so that regulations can be enforced. It is determined students’ perceptions of the effect of implementation also important that smoking should not be allowed in and of smoking restrictions and no-smoking signs on smoking outside cafeterias, outside lecture venues and entrances to behaviours. The majority of students had a high level of 44 S Afr Fam Pract 2017; 59(1):41–45

buildings. Nevertheless, having laws in place will on their own company of other smokers, which eventually led to resuming the not be sufficient; enforcement of these laws is also required. In habit. This is due to the social aspect of smoking, which during our study, the majority of the responses were accompanied by adolescence is a crucial motivating factor for smoking.19 dissatisfaction regarding the enforcement of the regulation, and not believing that the regulation had resulted in a reduction of Whilst many have tried to quit smoking in the past, they were smokers. Indeed, the majority of smokers also reported smoking unsuccessful but would like to stop doing so. However, more anywhere in and around campus, therefore being noncompliant than a third of smokers indicated that the smoking regulations with the policy. A stricter approach and better enforcement is have had no effect on their smoking behaviour. Thus further thus necessary for the policy to be effective. Campus security restrictions on smoking are necessary, particularly those should be strict in enforcing this law. Those breaking it can preventing smoking in public areas. Tobacco control programmes initially be given warnings and, if these fail, fines need to be should be tailored to motivate people to stop smoking. Although imposed. Such law enforcement is also required in public areas health warnings are present on cigarette packaging these are outside university. Smokers often exit the buildings and smoke clearly being ignored. An environment that reiterates these close to the entrances, therefore exposing others in those areas health warnings may be beneficial. We propose the placing of to second-hand smoke. Consequently, the regulation does not health warnings regarding smoking on bill-boards along main have the intended effect. Students would like to see more no- roads. Additionally, these warnings should include pictures of smoking signs in public places and this should be both on organ damage caused by tobacco smoking. Furthermore, university campuses and in other public places as well. The publicising these in newspapers and magazines would be TPCAA has restricted smoking to certain areas of restaurants, valuable. The more often people are confronted by warnings, bars and clubs but this is still not sufficient in protecting non- particularly those that include visual effects, it may be hoped smokers from the harmful effects of smoking and many have that this would have a meaningful impact on the cessation of indicated that they would like to have a complete ban on smoking. Moreover, an environment that is supportive of non- smoking in these places. It is particularly noteworthy that more smoking is required in order to decrease smoking behaviour non-smokers would like this extension to the ban. These findings when socialising. Signs in parks and gardens can designate these corroborate previous reports where American college students areas as non-smoking areas and in addition billboards in these also supported a total ban of smoking in restaurants.14 In the areas can promote clean, green spaces with the benefits of latter study the support for the ban was particularly high smoke-free air. These non-smoking open spaces need to be amongst those who were studying towards future employment extended to university grounds, which should also be designated in the hospitality industry and hoped to work in a smoke-free as no-smoking areas. environment, as they were also aware of the harmful effects of second-hand smoke.14 The intent of bans is to stop public We also show that living with at least one smoker in the smoking. This has to be aided with educational material and a household predicates smoking behaviour. In addition, this is also campaign to ensure that adolescents do not start the habit as harmful due to the effects of second-hand smoke. Exposure to they are very vulnerable at that age. The World Health peers and family members who smoke has also previously been Organization also noted that people who do not initiate the shown to make youngsters more likely to take up smoking.15 habit before the age of 20 are less likely to start smoking.15 Indeed, we also confirm that a correlation exists between a higher number of smokers in the household and taking up Moreover, campaigns that portray smoking in a bad light may be smoking. Attempts need to be made to discourage people from useful in preventing young people from taking up smoking since smoking in their homes. As this would be difficult to monitor, many started the habit as they thought it ‘seemed fun’. In order for campaigns need to emphasise the effects of smoking in the health education and knowledge of the harmful effects of presence of children so that parents can make a conscientious smoking to be a driver of change, priority needs to be the effort not to smoke in the company of their children. Furthermore, prevention of smoking in young people. Previous reports show our study showed smokers and ex-smokers were also more likely that mass media campaigns that target the young are effective in to have experimented with other smoked substances such as preventing the uptake of smoking in young people and that these drugs, thus causing more harm to their health. This corroborates campaigns which portray smoking in a bad light should include with the findings of a study stating that smokers have a greater multiple channels of communication such as newspapers, tendency towards participating in risky behaviour.20 We found television, radio, posters and information booklets.16 Our finding that the use of nicotine replacement therapies was extremely that the teenage years are the most likely age when people start low even though these are easily accessible. Perhaps the use of smoking is supported by a similar study in 2005.17 Stress was the these should be more widely advertised or encouraged in non- most common reason mentioned for commencement of smoking. smoking campaigns. The more recent e-cigarettes, which are We therefore propose that health education on the harmful supposed to assist in quitting of smoking, have not been around effects of smoking must begin at secondary or even primary long enough to assess their effects on long-term health and school level. It should focus not only on the harms of smoking but should not necessarily be encouraged. also teach stress coping mechanisms as well as other means of alleviating stress, for example through exercise. It must also be A limitation of the study is that a convenience sample was used noted that whilst smokers report that smoking relieves stress, the and it is therefore uncertain whether our results can be actual stress levels are higher in smokers than in non-smokers.18 generalised to all students or to other populations. Future studies There is also a worsening of moods among smokers.18 would be enhanced if students were selected from different academic levels of study as this may have an effect on smoking It is encouraging that over half the smokers wished to quit; behaviour. Second, despite data collection through a self- however, a large proportion tried to quit smoking but failed. administered questionnaire, our results may have been Withdrawal symptoms were a common reason for failure to quit.4 prejudiced by social-desirability bias. Future research also needs Another common cause for failure to quit was being in the to ascertain the time of and reasons thereof. Perceptions of students regarding the effects of the implementation of the tobacco control act of 1999 on a South African University campus 45

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